The clinical importance of polyp size measurement through two-dimensional saline infusion sonohysterography prior to hysteroscopic resection in predicting premalignant and malignant endometrial lesions.

OBJECTIVE: To evaluate the clinical importance of endometrial polyp size measured using saline infusion sonohysterography (SIS) before performing a hysteroscopic resection in predicting premalignant/malignant lesions. METHODS: A retrospective observational study analysis was conducted of 365 patients, who underwent SIS, in a reference hospital. The longest plane of the polyp size was taken as base. Polyps were classified as benign, premalignant, or malignant. RESULTS: The rates of premalignant and malignant lesions were 7.4% and 0.9%, respectively. The mean polyp size was 17.7 ± 0.5 mm in benign patients and 23.7 ± 1.8 mm in premalignant/malignant individuals (P < 0.001). In the group of polyps that were 0-10, 10-20, 20-30, and >30 mm, premalignancy/malignancy rates were 0.0%, 4.8%, 13.3%, and 18.8%, respectively. The cut-off value for polyp size to be able to predict lesions was calculated as 22.5 mm (sensitivity: 63%, specificity: 80%) on receiver operating characteristics curve analysis (P = 0.001, area under the curve 0.732). The power of the study was calculated as 90.86%. CONCLUSION: During the female reproductive years, endometrial polyps smaller than 10 mm, as measured in SIS, can be followed. However, when the polyp size is 22.5 mm or more, especially in postmenopausal women, treatment should be planned.

Could the Long-Term Oncological Safety of Laparoscopic Surgery in Low-Risk Endometrial Cancer also Be Valid for the High-Intermediate- and High-Risk Patients? A Multi-Center Turkish Gynecologic Oncology Group Study Conducted with 2745 Endometrial Cancer Cases. (TRSGO-End-001).

This study was conducted to compare the long-term oncological outcomes of laparotomy and laparoscopic surgeries in endometrial cancer under the light of the 2016 ESMO-ESGO-ESTRO risk classification system, with particular focus on the high-intermediate- and high-risk categories. Using multicentric databases between January 2005 and January 2016, disease-free and overall survivals of 2745 endometrial cancer cases were compared according to the surgery route (laparotomy vs. laparoscopy). The high-intermediate- and high-risk patients were defined with respect to the 2016 ESMO-ESGO-ESTRO risk classification system, and they were analyzed with respect to differences in survival rates. Of the 2745 patients, 1743 (63.5%) were operated by laparotomy, and the remaining were operated with laparoscopy. The total numbers of high-intermediate- and high-risk endometrial cancer cases were 734 (45%) patients in the laparotomy group and 307 (30.7%) patients in the laparoscopy group. Disease-free and overall survivals were not statistically different when compared between laparoscopy and laparotomy groups in terms of low-, intermediate-, high-intermediate- and high-risk endometrial cancer. In conclusion, regardless of the endometrial cancer risk category, long-term oncological outcomes of the laparoscopic approach were found to be comparable to those treated with laparotomy. Our results are encouraging to consider laparoscopic surgery for high-intermediate- and high-risk endometrial cancer cases.

Management of intra-abdominally translocated contraceptive devices, is surgery the only way to treat this problem?

This study was a multi-centre retrospective review of patients with uterine perforation caused by intrauterine contraceptive devices (IUDs). A total of 15 patients were registered, in a seven year period. Among them, five were asymptomatic and the rest were symptomatic. Asymptomatic patients were managed conservatively, except in one case in which the patient requested surgery because she also wanted a tubal ligation. Symptomatic patients all underwent surgery. All the surgeries were elective and all the surgical procedures were initiated laparoscopically. There were seven complications in the surgically managed group: conversion to laparotomy (n = 3), bowel injury (n = 2), bladder injury (n = 1), and wound infection (n = 1). Mild and severe adhesions (81.8%), and abscess (18.1%) formation related to translocated IUD (TIUD) were observed during surgery. All the patients were uneventful at 1 to 5 years of follow-up. A TIUD, by causing adhesions, complicates future laparoscopic surgery and increases the likelihood of conversion to laparotomy. While surgery is indicated to prevent TIUD-induced adhesive complications, it may also be the cause of both adhesions and complications, resulting in a vicious cycle. Some asymptomatic women, especially elderly patients with comorbidities, may not need or may be better managed without treatment. Impact statement In this study we try to find an answer for the question of "Should removal of a translocated intrauterine contraceptive device (TIUD) routinely be performed even if patients are asymptomatic?" From only the theoretical point of view there were some reports supporting conservative management in asymptomatic patients. The other studies addressing this issue were case reports including few patients with a short-term follow-up. The novelties of the present study include multi-centre design, detailed clinical and surgical information about the patients and the long period of follow-up. Most clinicians have limited experiences in managing TIUD because perforation is a rare event. So it can be difficult to know exactly what the surgeon will encounter intraoperatively. We undertook this study with the aim of providing a perspective about patients with TIUD for those faced with this situation. This is a descriptive study reporting 15 cases of TIUDs and management. Asymptomatic patients were managed conservatively, and symptomatic patients were operated. There are important implications resulting from this study that in asymptomatic patients leaving the IUD in place may be a reasonable option, mostly as the risk of surgical intervention is quite high with a high rate of complications with surgical management.

The diagnostic value of frozen section for borderline ovarian tumours.

Borderline ovarian tumours (BOTs) are characterised histologically by a low degree of cellular proliferation and nuclear atypia in the absence of infiltrative growth or stromal invasion. Surgical treatment has been a crucial component of BOT therapy. Surgical decisions are established intraoperatively via the frozen section. We evaluated the accuracy of frozen section diagnosis. The rate of correct diagnosis, underdiagnosis and overdiagnosis of BOTs with frozen sections was 78%, 17% and 5%, respectively. The sensitivity and positive predictive values for the diagnosis of BOTs with frozen sections were 82.3% and 93.3%, respectively. The positive likelihood ratio was 0.82 (95% CI: 0.85-0.96). The histological classification of BOTs had a significant effect on the accuracy of diagnosis (p = 0.001). Frozen section diagnosis is not suitable to be considered as the gold standard for a definitive diagnosis. Clinicians should be aware that using frozen sections is insufficient for the accurate staging of BOTs.

Does metoclopramide exposure alter endometrial receptivity and decrease pregnancy rates?

OBJECTIVE: The aim of this study was to investigate the effect of metoclopramide on endometrial receptivity with an immunohistochemical investigation of integrin ß3 expression in pregnant rats. MATERIALS AND METHODS: In the present study, the pregnant mice administrated by different doses of metoclopramide were used to explore the effect of metoclopramide on embryo implantation, especially on the endometrial receptivity. RESULTS: The statistical results showed that the number of implanted embryos was gradually declining along the increasing dose of metoclopramide. When the administrated dose of metoclopramide was 3 mg/kg per day, great changes were observed in the exposed uterine morphology and down-regulated integrin ß3 were also found in high dose metoclopramide-exposed mice. CONCLUSION: Metoclopramide exposure, especially in high doses may alter endometrial receptivity by effecting integrin expression on decidual tissue which can decrease pregnancy rates. This drug should only be recommended for use during pregnancy when benefit outweighs the risk.

Is Cryotherapy Friend or Foe for Symptomatic Cervical Ectopy?

OBJECTIVE: To evaluate the success rates and clinical outcomes of cervical cryotherapy applied to cervical ectopy for symptomatic relief. SUBJECTS AND METHODS: A total of 124 women who underwent cryotherapy for symptomatic treatment of cervical ectopy were included in this study. Indications for treatment were: abundant leucorrhoea (n = 114), post-coital bleeding (n = 22), recurrent cervicitis (n = 30) and pelvic pain (n = 12). Cryotherapy consisted of the use of carbon dioxide at -89°C to destroy the ectopic columnar epithelium by freezing, and it was transmitted to the ectopy through a flat cryoprobe. No routine anaesthesia or analgesia was administered. All patients were questioned about the status of their symptoms after 6 weeks of treatment. RESULTS: The highest success rate was obtained in patients with abundant leucorrhoea (n = 102; 89.5%), while the lowest success rate was achieved in subjects with pelvic pain (n = 7; 58%). After treatment, no severe complications were observed, except for hydrorrhoea for a few days. Success rates were 9 times lower in patients who had 3 or more cervicitis episodes per 6 months. CONCLUSION: In this study, the success rate of cryotherapy was highest in patients with abundant leucorrhoea and lowest in patients with pelvic pain and recurrent cervicitis. Hence, we recommend that clinicians perform the procedure in such patients without much delay.

Placenta percreta with concomitant uterine didelphys at 18 weeks of pregnancy: a case report and review of the literature.

AIM: The aim of this paper is to draw the attention of the clinicians on placenta percreta detected along with uterine anomalies in early second trimester. CASE PRESENTATION: A 35-year-old, gravida 2 parity 1 woman at 18 weeks of pregnancy was admitted to our emergency unit with abdominal pain. In ultrasound exam, a live fetus compatible with 18 weeks of gestation, hemoperitoneum and a solid mass adjacent to the uterus were detected. An emergent laparotomy was decided because of hemorrhagic shock findings. In the operation, uterine didelphys and an active bleeding area from placenta percreta on the anterior wall of the uterus where pregnancy was settled were detected. In the simultaneous vaginal examination two cervixes and a longitudinal vaginal septum were seen. Supracervical hemihysterectomy was performed. CONCLUSION: Placenta percreta is a rare clinical entity with an elevated perinatal mortality. Uterine anomalies are risk factors for placental adhesion anomalies. Clinical suspicion is vital for early diagnosis and timely management.

Comparison of maternal and fetal outcomes of IVF and spontaneously conceived twin pregnancies: three year experience of a tertiary hospital.

OBJECTIVES: The aim of this study was to compare maternal and fetal outcomes of spontaneously conceived and in-vitro fertilization (IVF) twin pregnancies that were admitted to our obstetric clinic and delivered between January 1, 2011 to November 1, 2014. MATERIAL METHOD: A total of 84 twin pregnancies were enrolled for the study and divided into two groups: group 1 as IVF (n = 19) and group 2 as spontaneously conceived (n = 65) twin pregnancies. Data of neonatal various morbidities needs neonatal intensive care unit (NICU) such as necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), sepsis, retinopathy of prematurity (ROP), and intraventricular hemorrhage (IVH) and maternal morbidities such as preeclampsia, eclampsia, postpartum bleeding, gestational diabetes mellitus(GDM) were collected by hospital records. RESULTS: There were no statistical difference between two groups regarding hypertension related to pregnancy, intrauterine growth retardation, Apgar scores, NICU needs, birth weight and height (P > 0.05). The rate of premature rupture of membranes, maternal age, antenatal anemia and premature birth were detected higher in IVF group when compared with the other group (P < 0.05). CONCLUSION: Although twin pregnancies, regardless of conception method are high risk pregnancies in terms of obstetric and perinatal outcomes, premature rupture of membranes, maternal age, antenatal anemia and premature birth risks are higher in IVF twin pregnancies.

A hidden reason for menopausal symptoms in premenopausal aged women: depression.

BACKGROUND: The relationship between depression and reproductive hormone changes in menopausal women is well konown but recent animal studies showed that depression can also cause changes in reproductive hormone levels. According to this, we aimed to eveluate the impact of depression on circulating follicle-stimulating hormone and estradiol levels in premenopausal women in terms of menopausal symptoms. MATERIAL-METHOD: A total of 120 premenoupausal women (age ranges 41-45) were divided into two groups as: study group consisted of patients (n = 60) with depression and the control group (n = 60) involved healthy women. Psychometric assessment of study group was done by the Turkish version of Structured Clinical Interview for DSM-IV Diagnosis.The presence of menopausal symptoms of all subjects was assessed by the Turkish version of Menopause Rating Scale and hormonal activity by estimating estradiol and follicle-stimulating hormone levels. RESULTS: Study group had significantly lower mean concentration of estradiol and higher intensity of menopausal symptoms than control group. Presence and severity of menopausal symptoms were not associated with follicle-stimulating hormone concentrations. CONCLUSION: The results of this study confirm the connection between menopausal symptoms and depression both on clinical and physiological level.The current study is unique in its ability to assess the effects of depression on menopausal symptoms in women as they are still reproductive.

The evaluation of homocysteine level in patients with preeclampsia.

OBJECTIVES: The aim of the study was to evaluate the correlation between preeclampsia and blood plasma homocysteine levels. MATERIAL AND METHODS: The research was conducted in a group of 114 pregnant patients who were subdivided into three groups consisting of: 30 women with severe preeclampsia, 24 with mild preeclampsia, and 60 healthy pregnant controls. Patient data included age, parity body mass index (BMI), systolic and diastolic blood pressure, homocysteine, folic acid, vitamin B12, hematocrit, hemoglobin, blood urine nitrogen, uric acid and urine analysis. RESULTS: There were no differences in the demographic characteristics (age, gravidity and BMI) among the groups. Mean serum homocysteine level was significantly higher in the preeclamptic group as compared to controls (p<0.01). Mean homocysteine level in the control group was significantly lower than in the severe and mild preeclampsia groups, respectively (p<0.001 vs. p<0.05). There were no statistically significant differences in homocysteine levels between mild and severe preeclampsia groups (p>0.05). Although there were statistically significant differences among the three groups in terms of BUN, creatinine, AST ALT and LDH, no statistically significant differences in serum folic acid, vitamin B12 and hemoglobin levels were found. CONCLUSIONS: Plasma homocysteine levels are significantly elevated in patients with preeclampsia and are not correlated with disease severity

A Rare Reason for Pelvic Pain in Pregnancy: Infectious Sacroiliitis.

Introduction. Although the incidence of pregnancy-associated sacroiliitis is low, it is associated with significant morbidity and mortality. Timely diagnosis of the disease is confusing due to its nonspecific clinical features. Case. A 28-year-old woman at 34 weeks of gestation with severe pain in her right buttock radiating down the backside of the right thigh was admitted to our hospital. White blood cell (WBC) count and C-reactive protein (CRP) were elevated. The pelvic magnetic resonance imaging (MRI) scan revealed right sacroiliitis. Conclusion. Infectious sacroiliitis should be considered as a differential diagnosis even in low-risk women who present with debilitating pelvic pain in pregnancy and medical treatment should not be delayed.

Laparoscopic removal of an intrauterine device from the sigmoid colon.

Uterine wall perforation which is commonly seen through the posterior wall of the uterus is the most serious complication of an intrauterine device (IUD). We present a case of laparoscopic removal of an IUD from the sigmoid colon in a 31-years-old female who was admitted to hospital with a history of pelvic pain and abnormal vaginal bleeding for one month. The dislocated IUD was removed from the sigmoid colon of laparoscopic intervention without any complications. In conclusion, the treatment modality for the removal of a dislocated IUD is possible by laparoscopic surgery in selected patients where the dislocated IUD is accessible.

Effects of maternal obesity on antenatal, perinatal and neonatal outcomes.

OBJECTIVE: Obesity is critically important to maternal and fetal health during the perinatal period. We have detected an increasing prevalence of maternal obesity in recent years and investigated its complications during pregnancy. METHODS: A total of 931 pregnant females were investigated between March 2012 and March 2013. The patients were divided into four groups: body mass index (BMI) < 18.5 kg/m(2) was underweight, 18.5-24.9 kg/m(2) was normal weight, 25-29.9 kg/m(2) was overweight and ≥30 kg/m(2) was obese. The effects of obesity on fetal and maternal outcomes were investigated. RESULTS: Significant increases in pregnancy-induced hypertension, gestational diabetes mellitus, cesarean delivery, premature rupture of membranes, shoulder dystocia, meconium-stained amniotic fluid, abnormal heart rate pattern and postpartum infection rates were found in the obese group during the perinatal period. Adverse maternal effects in obese cases were significantly more frequent than those in normal-weight cases. Preterm birth, perinatal mortality, low APGAR scores, newborn intensive care unit requirement, hypoglycemia and macrosomia rates were significantly higher in obese cases than those in non-obese cases. However, low birth weight infant rate was higher in the low BMI cases than that in the other BMI categories (p < 0.01). CONCLUSION: We conclude that obesity is an important factor associated with pregnancy complications and the increase in maternal-fetal morbidity and mortality.

Surgical Treatment of Scar Endometriosis Following Cesarean Section, a Series of 12 Cases.

It is difficult to conduct studies with larger series in rarely observed diseases. We report our experience in managing cesarean scar endometriosis (CSE) and emphasize the diagnosis and treatment options. The objective of our study is to review the clinical characteristics of CSE and to evaluate our surgical outcomes. We have collected and documented a case series of 12 patients who underwent surgical wide en bloc excision with surrounding clear margins for CSE. Patients' demographic features, symptoms, and clinical and operative findings were evaluated. The mean age was 34.6 years. Cyclical pain was documented in seven patients, while three patients presented with noncyclical pain. Menstrually-related enlargement of the nodule was observed in four patients, and only one patient had a complaint of dark brown leakage. The mean operation time was 26 min. The endometriotic lesions ranged from a diameter of 2 to 8 cm in size. Patients recovered completely, and no recurrence was observed. To prevent iatrogenic transplantation, additional attention is needed during surgery that exposes endometrial tissue. Complete wide excision of CSE is both diagnostic and therapeutic. To avoid unnecessary referrals, awareness of its typical clinical manifestations remains the mainstay for intervention. The most important issues to be considered during surgery is nonspreading endometriosis while manipulation.

Immediate repair of an incompletely transected obturator nerve during robotic-assisted pelvic lymphadenectomy.

Intraoperative injury of the obturator nerve may occur in gynecologic oncologic procedures when extensive pelvic side wall dissection is performed. In this case, we report an immediate repair of an incompletely transected obturator nerve during robotic-assisted pelvic lymphadenectomy. A 62-year-old gravida 3, para 3 woman was admitted to our clinic for postmenopausal bleeding. The result of an endometrial biopsy was complex endometrial hyperplasia with atypia, and a robotic-assisted laparoscopic hysterectomy was performed. A frozen section of the specimen revealed grade 1 endometrioid adenocarcinoma with >1/2 myometrial invasion. During the pelvic lymphadenectomy, the left obturator nerve was incompletely transected. The obturator nerve edges were oriented and reapproximated end-to-end with two 6/0 polypropylene sutures. The operation and console times were 244 and 223 minutes, respectively. The final pathologic finding was a stage IB endometrial adenocarcinoma. The number of the obtained lymph nodes was 38. Postoperatively, the patient did not exhibit any clinically apparent loss of adductor function or any other neurologic deficiency. Over 6 months of follow-up, the patient experienced no residual neuropathy or deficit in the left thigh. Robotic-assisted repair of a transected obturator nerve during surgery is feasible, and immediate repair of the damaged nerve may result in no neurologic deficit postoperatively.

Robotic-assisted dissection of bulky lymph nodes in cervical cancer.

The resection of bulky lymph node metastases, which may provide a therapeutic benefit, has been proposed in several studies based on laparotomy and laparoscopy. There is no published study in the literature examining the resection of bulky lymph node metastases using a robotic technique. In this report, we presented a patient with cervical cancer who underwent robotic-assisted dissection of bulky lymph nodes. The robotic-assisted operation time was 255 minutes, and the mean console time was 215 minutes. The estimated blood loss was 70 mL. The number of lymph nodes retrieved was 28, and the number of the dissected paraaortic lymph nodes was 13. The number of the lymph node metastases was eight. The bulky lymph nodes which are difficult to be eradicated with standard radiation therapy can be resected with robotic-assisted surgery and successful resection of the lymph nodes can improve the treatment strategy. This minimal invasive technique is safe and feasible for bulky lymph node dissection.

Four Cases of Chylous Ascites following Robotic Gynecologic Oncological Surgery.

Chylous ascites is an uncommon form of ascites characterized by milky-appearing fluid caused by blocked or disrupted lymph flow through chyle-transporting vessels. The most common causes of chylous ascites are therapeutic interventions and trauma. In this report, we present four cases of chylous ascites following robot-assisted surgery for endometrial staging and the treatment strategies that we used. After retroperitoneal lymph node dissection, leaving a drain is very useful in diagnosing chylous ascites and observing its resolution; furthermore, the use of octreotide in conjunction with TPN appears to be an efficient treatment modality for chylous ascites and should be considered before any invasive intervention.

Significance of foamy histiocytes in cervical smears from postmenopausal women.

OBJECTIVE: To determine the significance of the presence of foamy histiocytes (FH) in postmenopausal cervicovaginal smears for the detection of endometrial carcinomas (EC). STUDY DESIGN: Endometrial sampling was performed over 6 months in 53 of 102 cases that presented with postmenopausal FH, benign endometrial cells (BEC), FH with BEC (FH + BEC), and atypical endometrial cells (AEC), resulting in a total of 41,150 cervicovaginal smears. The control group consisted of 58 cases with a cytologic diagnosis of a normal smear (NS). RESULTS: There were 0 (0%), 1 (4.54%), 2 (13.33%), 2 (33.33%), and 5 (50.00%) cases of EC diagnosed on histopathologic evaluation in patients with NS (n = 58), BEC (n = 22), FH (n = 15), FH + BEC (n = 6), and AEC (n = 10), respectively. The sensitivities and specificities of the cytologic diagnoses of FH, FH + BEC, and AEC for the detection of EC were 81.7 and 100%, 93.6 and 100%, and 92.1 and 100%, respectively. CONCLUSION: The cytologic diagnoses of FH and FH + BEC had reasonably high sensitivities and specificities for the diagnosis of EC by cervicovaginal smear. Additional studies are needed.

Two Live Births following Robotic-Assisted Abdominal Cerclage in Nonpregnant Women.

Introduction. To report the robotic-assisted abdominal cerclage performed in two nonpregnant women and the success of live birth outcomes. Presentation of Cases. A 36-year-old woman with a complaint of recurrent second trimester pregnancy losses and a 35-year-old patient with a complaint of preterm deliveries and cervical insufficiency underwent robotic assisted abdominal cervicoisthmic cerclage placement in nonpregnant period. The two patients had spontaneous pregnancy after the robotic-assisted abdominal cerclage and delivered healthy infants. Discussion. The limitations of traditional laparoscopic abdominal cerclage have been accomplished with robotic surgery advantages especially intuitive movements and increased range of motion. There are only a few studies in the literature including robotic assisted abdominal cerclage in nonpregnant women, and only five successful live birth outcomes were reported. In this paper, we reported the sixth and seventh cases of achieved live pregnancy after robotic assisted abdominal cerclage in the literature. Conclusion. Robotic assisted abdominal cerclage is a good alternative surgical method with successful pregnancy outcomes.

Clinical significance of benign endometrial cells found in papanicolaou tests of Turkish women aged 40 years and older.

BACKGROUND: Spontaneously exfoliated benign-appearing endometrial cells (BEC) on a Papanicolaou smear might indicate endometrial pathology in postmenopausal women, necessitating further investigation. A cut-off age of 40 years was included in the Bethesda System 2001 based on studies of clinical significance of endometrial cells in Pap smears in Western countries. AIMS: The purpose of this study was to determine the significance of age subgroup for women with a cytological diagnosis of BEC, regardless of menopausal status, in a retrospective cohort of Turkish women. MATERIALS AND METHODS: Between October 2006 and November 2011, 41 patients with a BEC diagnosis and 64 patients with a cytological diagnosis of normal smear (NS) were enrolled; regardless of menopausal status, these women were 40 years and older and for whom follow-up endometrial biopsies had been performed. RESULTS: On subsequent histopathologic evaluation, no malignant lesion was detected in women aged 40-50 years compared to three endometrioid-type adenocarcinomas in women older than 50 years with cytological diagnosis of BEC. There was a significant difference between women older than 50 years with cytologic diagnosis of BEC and NS in relation to premalignant lesions on histopathologic evaluation; however, this was not the case for women aged 40-50 years. CONCLUSIONS: According to our study, reporting BEC for women aged between 40 and 50 years has minor clinical significance but is significant for women older than 50 years, regardless of menopausal status. Larger sample size would be appropriate to confirm the results of the current study.